{"paper_id":"22382cb4-0296-4bd2-af64-4db853541eb3","body_text":"Fathima, et al: Decoding xanthogranulomatous oophoritis: An uncommon ovarian inflammation\nCASE REPORT\nXanthogranulomatous Oophoritis: A Rare\nInflammatory Enigma of the Ovary\nZubiya Suha Fathima 1, Kalyani Raju 1, Pradeep Mitra 1, Sudarshan Krishnappa 1\nABSTRACT\nXanthogranulomatous oophoritis is an uncommon, chronic inflammatory condition of the ovary. Though\nxanthogranulomatous inflammation typically affects the endometrium, ovarian involvement is rare and\ncan be mistaken for malignancy due to similar clinical presentations. This condition is characterized by\nthe infiltration of lipid-laden histiocytes, plasma cells, lymphocytes, and neutrophils into ovarian tissue.\nA 29-year-old woman presented with abdominal pain radiating to her back and thighs, accompanied by\nintermittent fever. She had a history of intrauterine device (IUD) use and a previous episode of pelvic\ninflammatory disease (PID). A physical examination revealed tenderness in the left iliac fossa, and\nimaging studies showed a 7x7 cm left ovarian mass. Laboratory tests indicated mildly elevated CA 125\nlevels. Despite suspicions of malignancy based on imaging, histopathological analysis of the surgical\nspecimen revealed xanthogranulomatous oophoritis, characterized by sheets of foamy macrophages,\nplasma cells, and lymphocytes. Xanthogranulomatous oophoritis is a rare entity with few cases reported\nin the literature. It can mimic ovarian malignancy, making accurate diagnosis crucial. The condition\nis associated with factors such as chronic infection, ineffective antibiotic therapy, PID, endometriosis,\nand IUD use. Differential diagnoses include malakoplakia, which is distinguished by the presence of\nMichaelis-Gutmann bodies. Xanthogranulomatous oophoritis poses a significant diagnostic challenge\ndue to its resemblance to more aggressive pathologies. Awareness among clinicians is essential to avoid\nmisdiagnosis and over-treatment. Regular follow-up is recommended for patients with risk factors such as\nPID, endometriosis, and IUD use.\nKEY WORDS: Xanthogranulomatous Oophoritis, Ovarian Inflammation, Rare Ovarian Disorders,\nGranulomatous Inflammation, Ovarian Pathology, Inflammatory Ovarian Conditions.\nIntroduction\nXanthogranulomatous oophoritis is an uncommon,\nnonneoplastic, chronic process [1]. Xanthogranulo-\nmatous inflammation of the female genital tract is\nnot common and usually involves the endometrium;\nhowever, xanthogranulomatous inflammation of the\novaries is a rare entity [2]. Most frequent in females of\nreproductive age (range: 23 - 72 years), the Average\nage of patients with affected ovaries is 31 years [2].\nThe exact pathophysiology is unknown. Associated\nwith infection, ineffective antibiotic therapy. The\novarian involvement is rare and is characterized by\nAccess this article online\nQuick Response Code:\nWebsite: www.jmsh.ac.in\nDoi: 10.46347/jmsh.v11.i3.25.73\n1Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka, India\nAddress for correspondence:\nZubiya Suha Fathima, Sri Devaraj Urs Academy of Higher Education and Research, Kolar, Karnataka, India. E-mail:\nzubs95@gmail.com\na massive infiltration of the tissue with lipid-laden\nhistiocytes admixed with plasma cells, lymphocytes\nand polymorphonuclear leukocytes [3]. Few cases are\nreported in the literature of this entity and the current\ncase was reported given its rarity.\nCase Details\nA 29-year-old female was referred to the gyneco-\nlogical department of Sri Devaraj Medical College,\nKolar, India with complaints of pain abdomen for 15\ndays, which was radiating to the back and thighs,\nand intermittent fever on and off. Her menstrual\nhistory was normal with regular periods and her\nlast childbirth was 6 years ago. On examination, the\nabdomen was tender in the left iliac fossa region.\nP/V-uterus was normal in size, averted left forniceal\nfullness present. She had an IUD for a few years and\nexperienced an episode of PID after the IUD was first\ninserted. On bimanual palpation, 7x7 cm mass felt\nover left fornices. Routine investigations 7.5 gm%,\nTLC 15.40 Thousands/cumm. ESR 70mm/hr and\nJournal of Medical Sciences and Health /Sept-Dec 2025/Volume 11/Issue 3 357\n\nFathima, et al: Decoding xanthogranulomatous oophoritis: An uncommon ovarian inflammation\nother parameters were within normal range. A pap\nsmear showed NILM. CA 125 (Cancer antigen 125)\nwas mildly elevated – 45 IU/L (normal- 0-35 U/ml).\nSerum amylase and lipase levels were normal.\nOn USG abdomen and pelvis revealed a 7x6x6\ncm left ovarian mass that was suspected to be of\nmalignancy. On radiology (MRI-Pelvis) - Rt. Ovary:\nMeasures 3.0 x 3.2 x 3.1 cm, Vol ~ 11.0 cc with\nmultiple sub-centimetric peripherally arranged fol-\nlicles - Morphologically polycystic ovarian pattern.\nLt. Ovary: Diffusely bulky measures ~ 7.3 x 6.2\nx 6.3 cm, Vol ~ 140.0 cc. Shows the following\ncharacteristics. A well-defined T2 hyperintense, TI\nhypointense lesion measuring ~ 5.2 x 3.7 cm,\nshowing thick rim enhancement with central non-\nenhancement and diffusion restriction on DWI -\nLikely hemorrhagic cyst. The rest of the ovary\nappears heterogeneously hyperintense on T2 with\ndiffuse post-contrast enhancement and showing few\nperipheral follicles - S/o edematous changes. Few Tl\nhyper-intense foci were noted in the ovary showing a\nhypointense signal - S/o hemorrhagic areas.\nImpression\nBulky enhancing left ovary with hemorrhagic cyst\nand morphological features as described-Likely\ntorsion detorsion. The patient underwent surgery\n[laparoscopic assisted left cystectomy and left\noophorectomy], and the specimen was sent to the\nDepartment of Pathology of the institute.\nGross Microscopy (Observation)\nFigure 1: Left ovarian mass with attached fallopian tubes\nFigure 2: Histopathological photomicrograph of xan-\nthogranulomatous inflammation showing repacement of\novarian stroma by foamy macrophages and histiocytes (H\nand E, 40x)\nFigure 3: Histopathological photomicrograph of\nxanthogranulomatous inflammation showing foamy\nmacrophages, histiocytes, and plasma cells (H and E,\n400x)\nGross\nThe mass measured 8x6.5x5 cm. external surface of\nthe ovary-smooth, capsule breech was noted. The\nCut surface showed solid cytic areas, and it appeared\ngrey-white to grey-yellow with areas of necrosis.\nFrom the cystic area drained 4ml of serous fluid\n[Figure 1].\nHistopathology Report\nMicroscopy: Sections studied from the left ovar-\nian mass shows predominantly sheets of foamy\nmacrophages, many histiocytes, plasma cells, bin-\nucleated plasma cells, and lymphocytes [Figures 2\nand 3].\nAreas of normal ovarian tissue were also seen.\nfocal areas show necrosis. Occasional multinucleated\ngiant cells seen. The left fallopian tube shows\nlymphoplasmacytic infiltrates along with a few\nmacrophages.\n358 Journal of Medical Sciences and Health /Sept-Dec 2025/Volume 11/Issue 3\n\nFathima, et al: Decoding xanthogranulomatous oophoritis: An uncommon ovarian inflammation\nFeatures are consistent with features of xanthogran-\nulomatous oophoritis - Left ovarian mass.\nDiscussion\nXanthogranulomatous inflammation of the female\ngenital tract is unusual and is essentially limited to\nthe endometrium. Only a few cases involving the\novary have been reported [4,5].\nXantho-granulomatous oophoritis is a rare and\nunusual form of chronic oophoritis. It is also\ncalled ovarian fibroxanthoma. Xanthogranulomatous\ninflammation of the female genital tract usually\ninvolves the endometrium. But it can also affect\nfallopian tubes and ovaries. Kunakemakorn in 1976\nwas the first to report a case of xantho-granulomatous\ninflammation of the serosa of the uterus, left\nfallopian tube, and ovary. It presents as mass in the\npelvic cavity which can be misdiagnosed as ovarian\nmalignancy [3].\nThe exact etiopathogenesis of the disease is\nunknown. However, it can be associated with\ninfection, inappropriate antibiotic use, long-standing\npelvic inflammatory disease, endometriosis,\nintrauterine contraceptive devices, and uterine\nleiomyoma. Microorganisms such as Escherichia\ncoli, Proteus spp., Staphylococcus aureus, Bacteroides\nfragilis, Salmonella typhi, Actinomyces, Streptococcus\n(Enterococcus) faecalis, Viridans streptococci,\nTorulopsis (Candida) glabrata, and group B\nStreptococci are identified from the affected tissue [6].\nAnorexia, fever, and lower abdomen pain are\ncommon symptoms that patients experience when\nthey first come down with pelvic inflammatory\ndisease. A long history of using antibiotics is another\nfactor. It has been shown that xanthogranulomatous\noophoritis patients typically have low parity or\ninfertility [7]. In our case the patient presented with\npain abdomen, fever and also, she had a history of\nPID.\nAccording to Walther et al., the presence of\nfoam cells makes malakoplakia an important dif-\nferential diagnosis. This condition is then sepa-\nrated from xanthogranulomatous oophoritis by the\npresence of basophilic Michaelis-Gutmann bod-\nies, which are missing in the latter. Michaelis-\nGutmann bodies are cytoplasmic concentric calcific\nstructures that are indicative of malakoplakia and\nare absent in xanthogranulomatous inflammation [8].\nZiehl-Neelsen stain for acid-fast bacillus and periodic\nacid Schiff stain were negative in the present study,\nexcluding these possibilities. Later on, the follow-up\nof the patient was unremarkable.\nConclusion\nXanthogranulomatous oophoritis presents a sig-\nnificant diagnostic challenge, as its clinical and\nradiological manifestations often mimic malignancy\nand hemorrhagic cysts. Accurate diagnosis hinges\non thorough histopathological examination, making\nit crucial to differentiate this rare entity from more\naggressive pathologies. To avoid misdiagnosis and\nthe potential overdiagnosis of malignancy, aware-\nness of xanthogranulomatous oophoritis is essential\namong clinicians. Gynecologists and surgeons man-\naging patients with infertility, endometriosis, pelvic\ninflammatory disease (PID), intrauterine device (IUD)\nuse, and chronic infections should remain vigilant\nand consider regular follow-ups for patients at risk.\nDisclosure\nFunding: None\nConflict of Intereset: Nil\nReferences\n1. Bhatnagar K, Narang V, Garg B, Sood N. Xan-\nthogranulomatous Oophoritis: A Rare Case Report.\nIranian Journal of Pathology. 2018;13(3):372–376.\nAvailable from: https://pmc.ncbi.nlm.nih.gov/articles/\nPMC6322522/.\n2. Khan B, Aziz AB, Ahmed R. Case of Xanthogran-\nulomatous Oophoritis. Journal of Ayub Medical\nCollege Abbottabad. 2017;29(1):162–164. Available\nfrom: https://pubmed.ncbi.nlm.nih.gov/28712201/.\n3. Mundhra R, Gami N, Guleria K, Arora V, Garg S.\nRecurrent pyometra and xanthogranulomatous salpin-\ngitis: A rare pathologic association in a postmenopausal\nlady. Journal of Mid-life Health. 2014;5(3):156–158.\nAvailable from: https://dx.doi.org/10.4103/0976-7800.\n141227.\n4. Ladefoged C, Lorentzen M. Xanthogranulomatous in-\nflammation of the female genital tract. Histopathology.\n1988;13(5):541–551. Available from: https://dx.doi.org/\n10.1111/j.1365-2559.1988.tb02078.x.\n5. Pace EH, Voet RL, Melancon JT. Xanthogranulomatous\noophoritis: an inflammatory pseudotumor of the ovary.\nInternational Journal of Gynecological Pathology.\n1984;3(4):398–402. Available from: https://pubmed.\nncbi.nlm.nih.gov/6511165/.\n6. Gray Y, Libbey NP. Xanthogranulomatous salpingitis\nand oophoritis: a case report and review of the\nliterature. Archives of Pathology & Laboratory\nMedicine. 2001;125(2):260–263. Available from: https:\n//doi.org/10.5858/2001-125-0260-xsao .\nJournal of Medical Sciences and Health /Sept-Dec 2025/Volume 11/Issue 3 359\n\nFathima, et al: Decoding xanthogranulomatous oophoritis: An uncommon ovarian inflammation\n7. Suryawanshi KH, Damle RP, Dravid NV. Xan-\nthogranulomatous Oophoritis Mimicking as an Ovarian\nNeoplasm. Journal of Case Reports. 2014;4(1):100–\n103. Available from: https://dx.doi.org/10.17659/01.\n2014.0025.\n8. Walther M, Glenn JF, Vellios F. Xanthogranuloma-\ntous Cystitis. Journal of Urology. 1985;134(4):745–\n746. Available from: https://dx.doi.org/10.1016/s0022-\n5347(17)47421-0.\nHow to cite this article: Fathima ZS, Raju K, Mitra P,\nKrishnappa S. Xanthogranulomatous Oophoritis: A\nRare Inflammatory Enigma of the Ovary. J Med Sci\nHealth 2025; 11(3):357-360\nDate of submission: 19.02.2025\nDate of review: 15.03.2025\nDate of acceptance: 23.05.2025\nDate of publication: 14.05.2025\n360 Journal of Medical Sciences and Health /Sept-Dec 2025/Volume 11/Issue 3","source_license":"CC0","license_restricted":false}